| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
166 |
$32K |
| D1351 |
Sealant - per tooth |
691 |
185 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
133 |
$19K |
| D1110 |
Prophylaxis - adult |
288 |
286 |
$17K |
| D1206 |
Topical application of fluoride varnish |
583 |
572 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
484 |
475 |
$17K |
| D0330 |
Panoramic radiographic image |
174 |
173 |
$15K |
| D0274 |
Bitewings - four radiographic images |
326 |
323 |
$14K |
| D1120 |
Prophylaxis - child |
311 |
301 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
165 |
$11K |
| D0272 |
Bitewings - two radiographic images |
224 |
219 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
27 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
109 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
17 |
$2K |
| D2335 |
|
15 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
20 |
$671.00 |